Procaccini v. Lawrence and Memorial Hospital, Inc.

Action
to recover damages for medical malpractice, and for other
relief, brought to the Superior Court in the judicial
district of New London, where the action was withdrawn as
against the named defendant et al.; thereafter, the plaintiff
filed an amended complaint as against the defendant Emergency
Medicine Physicians of New London County, LLC; subsequently,
the matter was tried to the jury before Hon. Joseph Q.
Koletsky, judge trial referee; verdict for the
plaintiff; thereafter, the court denied the motions to set
aside the verdict and for a directed verdict filed by the
defendant Emergency Medicine Physicians of New London County,
LLC, and rendered judgment in accordance with the verdict,
from which the defendant Emergency Medicine Physicians of New
London County, LLC, appealed to this court.
Affirmed.

Daniel
J. Krisch, with whom were Frederick J. Trotta, Sr., and, on
the brief, Logan A. Forsey and Jennifer S. Mullen, for the
appellant (defendant Emergency Medicine Physicians of New
London County, LLC).

Matthew E. Auger, with whom, on the brief, was Eric W.
Callahan, for the appellee (plaintiff).

Prescott, Mullins and Beach, Js.

Syllabus

The
plaintiff administrator of the estate of the decedent sought
to recover damages from the defendant E Co. for medical
malpractice inconnection with the death of the decedent by a
methadone overdose. On November, 29, 2008, the decedent was
found unresponsive and was brought to a hospital emergency
department, where she was treated for a suspected drug
overdose by M, the attending emergency department physician.
After the decedent's vital signs improved and stabilized,
she was discharged and returned to the home of a friend,
where she was found unresponsive the next morning and
pronounced deceased. The plaintiff alleged that E Co. was
vicariously liable for the medical malpractice of M in
treating the decedent for a suspected drug overdose. The
plaintiff claimed that M's discharge of the decedent
after only four and one-half hours of observation was
premature in that M should have kept the decedent under
medical monitoring for twenty-four hours, which is the period
of time during which the fatal side effects of methadone
toxicity may occur, and that if the decedent had remained
under medical monitoring for the full twenty-four hours, the
fatal overdose side effects she experienced after her
discharge would have been treated and her eventual death from
methadone toxicity would have been averted. The jury returned
a verdict for the plaintiff, and the trial court rendered
judgment in accordance with the verdict, from which E Co.
appealed to this court. E Co. claimed, inter alia, that there
was no direct evidence as to when the decedent consumed the
fatal dose of methadone, and that the undisputed scientific
evidence established that if she had actually overdosed on
methadone on November 29, 2008, she would have had a
recurrence of overdose symptoms before she was discharged
from the hospital's emergency department. Held:

1.
There was sufficient evidence to support the jury's
finding that E Co.'s negligence caused the decedent's
death:

a. The
jury had before it sufficient evidence from which it could
have inferred, without resorting to speculation, that the
decedent had consumed the fatal dose of methadone before she
was brought to the emergency department on November 29, 2008:
although the jury was presented with conflicting expert
testimony as to how soon a methadone overdose patient would
experience recurring overdose symptoms after receiving a
certain medication that is used as an antidote for opiate and
opioid overdoses, the jury was free to believe the opinion of
the plaintiff's expert witness, S, on the standard of
care, that delayed, recurring respiratory depression can
occur in methadone overdoses, even if such a phenomenon
defied certain undisputed and settled toxicology principles,
and to disbelieve those portions of the testimony of E
Co.'s expert witness, P, on causation, that attempted to
refute that phenomenon, and E Co.'s claim that it was
improper for the jury to consider S's testimony
concerning the concept of delayed, recurring respiratory
depression as it related to causation was unavailing because
even if S's testimony was offered strictly for standard
of care purposes, E Co. failed to pursue any preemptive or
remedial measures that would have precluded or limited
S's testimony on the issue of delayed, recurring
respiratory depression, and the court never instructed the
jury that it should disregard S's testimony thereon or
that it should consider such testimony only for standard of
care purposes, and, therefore, the evidence regarding
delayed, recurring respiratory depression was before the jury
to use for any purpose, including causation; moreover, the
fact that the decedent did not immediately experience
recurring overdose symptoms one hour after the overdose
medication was administered did not require the jury to
conclude that the decedent's overdose on November 29,
2008, was caused by a narcotic other than methadone, as the
jury could have concluded, instead, that the delayed,
recurring respiratory depression that the decedent eventually
experienced was consistent with her ingestion of a toxic dose
of methadone before her visit to the emergency department on
November 29, 2008.

b. E
Co. could not prevail on its claim that because the plaintiff
failed to present evidence demonstrating that the decedent
would have been admitted to the hospital had M not discharged
her from the emergency department, the jury could not
reasonably have found that E Co. caused the decedent's
death: although the plaintiff's expert, S, initially
testified that the standard of care applicable to possible
methadone overdoses required M to admit the decedent to the
hospital for continuous monitoring, S subsequently clarified
that the applicable standard of care required only that M
monitor the decedent for twenty-four hours for signs of
recurrent opiate overdose, and the jury reasonably could have
accepted that portion of S's testimony indicating that
monitoring was required and rejected that portion of his
testimony suggesting that admittance was required;
accordingly, to prove causation, the plaintiff needed to show
only that the decedent could have been monitored sufficiently
for twenty-four hours, and the jury reasonably could have
inferred that from the evidence presented.

2. The
trial court did not abuse its discretion in denying E
Co.'s motion to set aside the jury's award of $150,
000 in damages for the destruction of the decedent's
capacity to carry on and enjoy life's activities; the
jury reasonably could have forecast the decedent's life
expectancy from its own knowledge and from the substantial
evidence presented by the plaintiff of the decedent's
age, health, physical condition and habits, all of which were
relevant to determine life expectancy, and, therefore, the
jury's award of damages for the destruction of the
decedent's capacity to carry on and enjoy life's
activities was not unreasonable or speculative.

OPINION

MULLINS, J.

In this
medical malpractice action, the defendant[1] Emergency
Medicine Physicians of New London County, LLC, appeals from
the judgment of the trial court, after a jury trial, rendered
in favor of the plaintiff, James M. Procaccini, administrator
of the estate of Jill A. Procaccini (decedent). On appeal,
the defendant claims that there was insufficient evidence
supporting the jury's verdict and award of noneconomic
damages. Specifically, it claims that the plaintiff failed to
present sufficient evidence for the jury (1) to find that the
defendant's negligence caused the death of the decedent,
and (2) to award $150, 000 in damages for the destruction of
the decedent's capacity to carry on and enjoy life's
activities. We affirm the judgment of the trial court.

The
following facts, as reasonably could have been found by the
jury, and procedural history are relevant to this appeal. On
November 30, 2008, the decedent, who was thirty-two years
old, died from a methadone overdose. In the years leading up
to her death, the decedent had struggled with polysubstance
abuse.

After
achieving a period of sobriety early in 2008, the decedent
relapsed on November 16, 2008. On that date, the decedent
admitted herself to Saint Francis Hospital and Medical Center
in Hartford (Saint Francis), seeking treatment for a heroin
overdose. On the next day, November 17, 2008, the decedent
was transferred to Cedarcrest Hospital, Blue Hills Substance
Abuse Services (Blue Hills), in Newington.

The
decedent remained at Blue Hills from November 17, 2008, until
her discharge on November 28, 2008. During her stay at Blue
Hills, the decedent was administered varying doses of
methadone for treatment of her opiate withdrawal symptoms.
Methadone, an opioid, [2]frequently is used by clinicians to
alleviate the withdrawal symptoms that patients experience
while undergoing opiate detoxification. Although methadone
commonly is used in the clinical setting and, thus,
administered under a clinician's supervision or pursuant
to a prescription, it also can ‘‘be purchased
[illegally] on the streets as street methadone.'' The
decedent's last dose of methadone, five milligrams, was
administered at Blue Hills at 7:45 a.m. on November 21, 2008.
The decedent was discharged from Blue Hills on November 28,
2008.

After
leaving Blue Hills on November 28, 2008, the decedent made at
least two phone calls. One of those calls was to a person
from whom the decedent had purchased drugs in the past.
Another call was to Charles Hope, a substance abuse counselor
and a recovering drug addict with whom the decedent was
friendly. Hope agreed to let the decedent stay at his house
in New London on the condition that she not use drugs. Hope
picked up the decedent from West Hartford on the evening of
November 28, 2008, and brought her to his home in New London.
Upon their arrival at Hope's home, Hope and the decedent
talked briefly and then retired for the night. Hope heard the
decedent use the microwave in his kitchen at some point
during the night.

On the
morning of November 29, 2008, Hope woke up the decedent and
noticed that she was ‘‘feeling a little
sick.'' Hope left his home sometime in the late
morning or early afternoon of November 29. Hope later called
the decedent sometime that afternoon and had a conversation
with her. When Hope returned to his home at approximately
6:45 p.m., however, he found the decedent lying unconscious
on his living room couch. Hope began performing
cardiopulmonary resuscitation, which restored the
decedent's breathing. At approximately 6:47 p.m., Hope
called 911.

Emergency
medical technicians (EMTs) from the New London Fire
Department arrived at Hope's house on November 29, 2008,
at approximately 6:51 p.m. The EMTs found the decedent
unresponsive, lying in a supine position in Hope's living
room with pinpoint pupils and agonal respirations. Hope told
the EMTs that the decedent ‘‘had been on
methadone, '' that the decedent ‘‘had a
history of addiction, '' and that he was unsure if
she used drugs that day. Because she was unconscious,
however, the EMTs were unable to obtain any medical history
from the decedent. The EMTs administered oxygen to the
decedent via an oral airway and bag valve mask. Hope and the
EMTs briefly searched Hope's house for drugs, drug
paraphernalia, and other evidence of drug use. They did not
find any such evidence.

Shortly
thereafter, at approximately 6:55 p.m., paramedics from
Lawrence & Memorial Hospital (Lawrence & Memorial)
arrived on the scene. The paramedics placed the decedent in
their ambulance. At some point between 6:55 p.m. and 7:03
p.m., the paramedics intravenously administered the decedent
1.4 milligrams of Narcan.

Narcan
is used as an ‘‘antidote'' for opiate and
opioid overdoses. Narcan, like opiates and opioids, attaches
to the opioid receptors located in the body's central
nervous system. Narcan, however, does not cause any of the
effects that opiates and opioids produce, such as pain
relief, a ‘‘high'' feeling, and
respiratory depression. Instead, because opioid receptors
have a ‘‘stronger affinity for the Narcan
molecule than [they do] for [opiates and opioids], ''
Narcan ‘‘just knocks [opiates and opioids] out
and takes residency in the receptor[s] . . . .''
‘‘[Once] [t]he Narcan displaces the opiate [or
opioid] from the receptor[s] . . . the person's opiate
effects evaporate . . . the person wakes up and [he or she
is] breathing and . . . alert . . . .'' In other
words, ‘‘intravenous administration of Narcan . .
. pro- duce[s] a near-instantaneous reversal of the narcotic
effect . . . within a minute or two at the most . . .
.''

By the
time the ambulance arrived at Lawrence & Memorial at 7:03
p.m., the dose of Narcan had revived the decedent. The
decedent was conscious and answering questions asked by the
paramedics. The paramedics were able to determine that the
decedent was taking several medications, including methadone,
Topamax, Seroquel, insulin, and Ambien. In their written
report, the paramedics indicated that the ‘‘chief
complaint'' was an ‘‘[overdose] on
Heroin'' and that the decedent was
‘‘found in respiratory arrest due to
[overdose].''

Upon
arriving at Lawrence & Memorial, the decedent was taken
to the emergency room, where her condition was triaged. In
examining the decedent, the triage nurse, Sarah Zambarano,
created an electronic report detailing the decedent's
condition at 7:13 p.m. Zambarano indicated in the electronic
report that the paramedics informed her that Hope told them
that the decedent ‘‘took methadone, ? of
heroin.''

At
approximately 7:15 p.m., the decedent was assessed by another
emergency room nurse, Pamela Mays. At 7:36 p.m., Mays
recorded the following in her treatment notes:
‘‘[the decedent] admits to using heroin to
ni[ght] . . . states off methadone for several months after
detox . . . now using again.'' Mays also indicated
that the decedent ‘‘appear[ed]
comfortable'' and was ‘‘cooperative,
'' ‘‘alert'' and
‘‘oriented . . . .'' Contrary to
May's notes, Hope, who had arrived at the emergency room
between 7:30 p.m. and 8 p.m., recalled that the decedent was
‘‘very adamant that she did not take any heroin .
. . .'' According to Hope, the decedent told Mays
that ‘‘I did not take any heroin, I took
methadone.''

At
approximately 7:45 p.m., the attending emergency room
physician, Thomas E. Marchiondo, examined the decedent. At
the time he began treating the decedent, Marchiondo had
access to the paramedics' report, which indicated that
the decedent had a suspected overdose on heroin, that the
decedent also was taking methadone, and that the decedent had
been found in respiratory arrest. Marchiondo detailed his
examination of the decedent in his own written report. In his
report, Marchiondo noted that the decedent's
‘‘chief complaint'' was an
‘‘unintentional heroin overdose.''
Although the decedent apparently denied any
‘‘other co-ingestion, '' Marchiondo's
report indicated that the decedent's
‘‘current medications'' included
methadone.

Marchiondo's
report also indicated that a urine toxicology screen had been
ordered. The results of the screen, of which Marchiondo was
aware when treating the decedent, revealed that the
decedent's urine tested positive for the presence of
methadone, an unidentified opiate, and unidentified
benzodiazepines. Because that screen merely was qualitative,
it could not identify the specific type of opiate ingested by
the decedent or the exact concentration of that substance or
methadone in the decedent's system.

As a
result of his review of the drug screen results, as well as
his examination of the decedent and review of the treatment
notes prepared by the nurses and emergency responders,
Marchiondo concluded that the decedent had ingested both
methadone and heroin. Regarding the methadone, although he
could not determine specifically when or in what manner the
decedent ingested it, Marchiondo concluded that the decedent
ingested some quantity of methadone ‘‘within the
past couple of weeks.'' In so concluding, Marchiondo
relied on the fact that methadone was listed as a medication
in her medical history, which caused him to believe that the
decedent was taking the methadone ‘‘under a
doctor's prescription . . . .'' Marchiondo
consequently ‘‘would have expected [methadone] to
come out positive in her urine.'' Accordingly, he
concluded that the overdose symptoms that the decedent was
experiencing ‘‘were due to a heroin
overdose'' and agreed with a statement by the
plaintiff's counsel that the decedent's symptoms
‘‘[were] in no way related to the methadone that
was in her system.''[3]

The
decedent remained in the Lawrence & Memorial emergency
room from 7:13 p.m. to approximately 11:53 p.m. on November
29, 2008. ‘‘All throughout her stay . . . [the
decedent] remained awake, alert, and aware, nontoxic. And
through time . . . her vital signs had improved.''
Hope, who had stayed with the decedent at her bedside, also
observed that, although initially the decedent seemed, as
characterized by the defendant's counsel,
‘‘sluggish, '' her condition continued to
improve and she was ‘‘laughing and making
jokes.'' During her hospitalization at Lawrence &
Memorial, the decedent was not administered any Narcan.
Marchiondo had determined that it was not necessary to treat
the decedent with Narcan because her vital signs had improved
while she was at Lawrence & Memorial.

Throughout
her stay, the decedent was monitored by Mays, who noted in
her report that the decedent's vital signs improved and
stabilized. At approximately 8 p.m., the decedent was
‘‘awake and alert and asking to leave . . . [but
was] told that she was here for the night.'' At this
point, the decedent's respiration rate had improved to
sixteen breaths per minute, and her oxygen saturation level
had risen to 99 percent. These levels were
‘‘basically normal.'' The decedent also
had been taken off supplemental oxygen.

At 9
p.m., the decedent was ‘‘resting
soundly'' and her ‘‘[respiration was]
easy/even.'' Her respiration rate and oxygen
saturation level had not changed since 8 p.m. At 10 p.m. and
11:30 p.m., the decedent's respiration rate still was
sixteen breaths per minute, and her oxygen saturation level
still was 99 percent. At some point between 11:35 p.m. and
11:53 p.m., the decedent was discharged and was provided
instructions for a ‘‘narcotic overdose,
'' which advised the decedent to
‘‘[r]eturn to the ER if [her condition]
worse[ned].''

Upon
being discharged from Lawrence & Memorial, the decedent
left with Hope. Hope and the decedent stopped for food and
coffee before returning to Hope's home. At Hope's
home, Hope and the decedent conversed until approximately
1:30 a.m. on November 30, 2008, at which point, Hope went to
bed. When Hope left the decedent to go to bed, the decedent
was kneeling on the corner of the bed in Hope's guest
bedroom, watching television and looking at photographs. Hope
did not hear any activity during the night.

After
waking up at approximately 9:45 a.m. later that morning, Hope
found the decedent unresponsive. The decedent's body was
‘‘frozen stiff'' and kneeling in the same
position in which she had been on Hope's guest bed when
Hope last saw her at 1:30 a.m. earlier that morning. Hope
called 911 at approximately 10:39 a.m.

New
London police, accompanied by New London Fire Department
EMTs, arrived at Hope's home on November 30 at
approximately 11 a.m. The decedent was pronounced deceased by
the EMTs at approximately 11:05 a.m. Thereafter, Hope
assisted the police in searching his entire house for drug
paraphernalia and other evidence of drug use. Neither Hope
nor the five law enforcement officers searching the scene
found anything relating to drug activity.

At
approximately 1:34 p.m., Penny Geyer, an investigator with
the Office of the Chief Medical Examiner, arrived at
Hope's home. At the scene, Geyer performed an external
examination of the decedent's clothed body. She did not
find any illicit drugs or drug paraphernalia on or around the
decedent's body, and she did not observe any signs of
drug ingestion on the decedent's body, such as needle
marks or residue in the decedent's nose or mouth.

Deputy
Chief Medical Examiner Edward T. McDonough III performed the
decedent's autopsy on December1, 2008. A toxicology
screen ordered by McDonough detected the presence of
methadone in the decedent's blood. Specifically, the
report indicated that the concentration of methadone in the
decedent's blood was 0.39 milligrams per liter. The
postmortem toxicology screen did not detect any opioids or
opiates other than methadone.

As a
result of his review of the toxicology report and his
examination of the decedent, McDonough concluded that the
final cause of the decedent's death was
‘‘methadone toxicity.'' In so concluding,
McDonough determined that the postmortem concentration of
methadone in the decedent's blood, 0.39 milligrams per
liter, was ‘‘within the fatal range.''
McDonough also deter- mined that the decedent died sometime
between 5 a.m. and 7 a.m. on November 30, 2008, although this
was merely a ‘‘crude'' approximation
because the time of death could have been ‘‘much
earlier.''

In
November, 2010, the plaintiff, acting as the administrator of
the decedent's estate, brought this medical malpractice
action seeking damages for the decedent's death. The
plaintiff's initial complaint asserted one count against
Marchiondo, one count against Lawrence & Memorial
Hospital, Inc., and Lawrence & Memorial Hospital
Corporation, and one count against the defendant. Following
the plaintiff's withdrawal of the separate counts against
Marchiondo and Lawrence & Memorial Hospital, Inc., and
Lawrence & Memorial Hospital Corporation; see footnote 1
of this opinion; the plaintiff amended his complaint to seek
recovery from only the defendant.

The
plaintiff's operative complaint alleges that the
defendant is vicariously liable for the medical malpractice
that its employee, [4] Marchiondo, committed in treating the
decedent for a suspected drug overdose on November 29, 2008.
The gravamen of the plaintiff's complaint is that
Marchiondo's discharge of the decedent after only four
and one-half hours of observation at Lawrence & Memorial
was premature. According to the plaintiff, because the
decedent presented with a possible methadone overdose,
Marchiondo should have kept her under medical monitoring for
twenty-four hours, which is the period of time during which
the fatal side effects of methadone toxicity may occur.
Accordingly, the plaintiff alleges, if the decedent had
remained under medical monitoring for the full twenty-four
hours, the fatal overdose side effects she experienced after
her discharge would have been treated and her eventual death
from methadone toxicity would have been averted.

In his
complaint, the plaintiff sought both economic and noneconomic
damages resulting from the decedent's death. The claim
for economic damages included medical expenses and funeral
costs, and the claim for noneconomic damages sought
compensation for the decedent's permanent loss of her
ability to carry on and enjoy life's activities.

After
the plaintiff rested, the defendant moved for a directed
verdict. Specifically, the defendant argued that
‘‘the plaintiff [had] not submitted sufficient
evidence to establish a prima facie case with respect to
causation.'' (Emphasis added.) The defendant did
not challenge the sufficiency of the evidence regarding the
appropriate standard of care and the defendant's breach
thereof. The court reserved decision on the defendant's
motion for a direct verdict.

The
jury returned a plaintiff's verdict and awarded $12, 095
in economic damages and $500, 000 in noneconomic damages. The
award consisted of $350, 000 for the decedent's death and
$150, 000 for the destruction of the decedent's capacity
to carry on and enjoy life's activities.

After
the jury returned its verdict, the defendant renewed its
motion for a directed verdict.[5] As in its initial motion, the
defendant challenged the sufficiency of the evidence only
with respect to causation: ‘‘[T]he evidence
presented by the plaintiff during his case-in-chief [was]
insufficient to support a conclusion that any alleged
negligence on the part of the defendant was the cause in fact
of the death of [the decedent].'' Specifically, the
defendant argued that there were ‘‘two missing
links in the plaintiff's chain of causation: (1) that
[the decedent] overdosed on methadone on [November 29, 2008];
and (2) that [the decedent] met the criteria for admission to
[Lawrence & Memorial].''

Regarding
the first ‘‘missing link, '' the
defendant contended that ‘‘the jury had no
basis-other than conjecture-to find that [the decedent]
overdosed on methadone on November 29, [2008]. To the
contrary, science and the chronology of events point only to
the ‘reasonable hypothesis' that [the decedent]
took the lethal dose of methadone after Dr.
Marchiondo discharged her.'' (Emphasis in original.)

Regarding
the second ‘‘missing link, '' the
defendant contended that ‘‘the jury could only
guess about another critical piece of the puzzle: admission
to [Lawrence & Memorial]. . . . [T]here was no evidence
about [Lawrence & Memorial's] criteria for admission,
or whether [the decedent] met those criteria.''
According to the defendant, the applicable standard of care
required Marchiondo to admit the decedent to Lawrence &
Memorial. Thus, the defendant posited, the plaintiff could
not prove that Marchiondo's breach of that ...

Our website includes the first part of the main text of the court's opinion.
To read the entire case, you must purchase the decision for download. With purchase,
you also receive any available docket numbers, case citations or footnotes, dissents
and concurrences that accompany the decision.
Docket numbers and/or citations allow you to research a case further or to use a case in a
legal proceeding. Footnotes (if any) include details of the court's decision. If the document contains a simple affirmation or denial without discussion,
there may not be additional text.

Buy This Entire Record For
$7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.